Laserfiche WebLink
SAN JOAQUI IUNTY ENVIRONMENTAL HEALTH OrTMENT <br />SERVICE REQUEST <br />Type of Business or Proprty ,. q . i av-iiriton+ Cunt ie-Y <br />FACILITY ID # 1 <br />kr)-5 \. <br />SERVICE REQUEST # <br />5 a-06% 5 3 3 <br />OWNER! OPERATOR 0 1 <br />ivc arK_ 16-eari-m-€.1)+-E. CHECK if BILLING ADDRESS Er <br />FACIUTY NAME <br />0 1 i V e., ?ar K 4 ,i.r-i--rne n+ S <br />SITE ADDRESS <br />iclE Street Number Number Direction <br />4 e, bg AfOrfhg ''.- Let Name <br />3 # <br />._. <br />-: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name Zi"..: -1 -,:r <br />CITY STATE ZIP FO :I <br />....i <br />PHONE #1 <br />(62(N ) 023(1 /y//0 <br />APN # LAND USE APPLICATION # '' , ,, —ri m71: - mil' <br />- L If, <br />PHONE #2 E. BOS DISTRICT tOdATIONIZDE <br />-i <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 3a(" r o e r S <br />CHECK if BILLING ADDRESS FM 1 <br />BUSINESS NAME e , Ycni Seyvicf., ao (I 'Re r <br />PHONE # EXT. <br />(209) 5 161-02 33 <br />HOME or MAILING ADDRESS 342o Wmc hes+er C.,+- • FAX # (aoq ) 522- ._5-1 3 <br />CITY yiindesib OTTE ZIP q 5355 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNERUI OPERA Øu/ / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: fl(, <br />COMMENTS: <br />ACCEPTED BY: n EMPLOYEE #: ()(146 7 DATE: <br />ASSIGNED TO: <br />6 EMPLOYEE #:e.) (.4 "4- DATE: <br />6E,X) ) ( <br />Date Service Completed Of already completed): .041c4 I ii sY illi li .i. 1 V STI <br />IV <br /> <br /> f4.7.;W: -1,Ji3 _I <br />SERVICE CODE: O& / <br />I : 3'c, 3 <br />Fee Amount: -:;! it,:: -I <br />_ <br />AmoUd‘PlArd!-1 I t '. tiv? Sy ot-L5 Payment Date S---/C?( 6-7 <br />Payment Type ,__- Invoice # 61 :Z 14c! k-cinViniu hj(-D <br />Received By: <br />/3/O7 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003